Rural health roundtables: a strategy for ... - Rural and Remote Health

PROJECT REPORT

Rural health roundtables: a strategy for collaborative engagement in and between rural communities CL Pennel, SL Carpender, BJ Quiram Texas A&M Health Science Center School of Rural Public Health, College Station, Texas, USA Submitted: 5 August 2008; Resubmitted: 6 November 2008; Published: 18 November 2008 Pennel CL, Carpender SL, Quiram BJ Rural health roundtables: a strategy for collaborative engagement in and between rural communities Rural and Remote Health 8: 1054. (Online), 2008 Available from: http://www.rrh.org.au

ABSTRACT

Introduction: The lack of formal public health infrastructure and trained health professionals in rural areas has a deleterious impact on rural populations for various health issues. The purpose of this article is to: (1) suggest a strategy regularly used by the authors that encourages relationship building and serves as a catalyst for rural communities to work together to initiate and make changes based on the local assets and dynamics; (2) provide a descriptive overview of this strategy; and (3) provide an illustrative case, using the Rural Ready Communities project, in which this strategy has been used. Methods: The Rural Health Roundtable strategy includes identifying relevant topics and stakeholders; using specific methods to ensure stakeholder attendance; creating an informal, social environment where participants feel comfortable sharing; utilizing targeted questions to engage participants and empower local ownership; and following up with the participants through communication and evaluation. Results: The Rural Health Roundtable strategy can result in short-term, intermediate and long-term outcomes using various evaluation tools and methods. Conclusions: The Rural Health Roundtable strategy has demonstrated its value as an effective tool in working with rural communities. With fewer human and financial resources at their disposal, this strategy can aid rural communities in identifying and

© CL Pennel, SL Carpender, BJ Quiram, 2008. A licence to publish this material has been given to ARHEN http://www.rrh.org.au

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utilizing their unique strengths to overcome resource deficits when responding to public health emergencies and natural disasters. Initiated in 1999, the methodology has been refined and enhanced over the past 8 years to more effectively reach stakeholders, ensure attendance and participation, promote sharing and discussions, build stakeholder networks and encourage continued communication and collaboration. The Rural Health Roundtable strategy has significant potential for replication and application to all areas of rural public health. Key words: capacity building, community networks, emergency planning, public health system, USA.

Introduction There has been sufficient documentation to establish that the public health infrastructure in the USA is deteriorating throughout all geographic regions. Healthy People 2010 identifies public health infrastructure (Focus Area 23) as one of 28 necessary focus areas to achieve the two overarching HP 2010 goals, to: (i) increase quality and years of healthy life; and (ii) eliminate health disparities1. While there has been a fair amount of research and discussion about general public health infrastructure issues, little attention has been given to the rural dimensions of this topic2. The special issues and considerations of rural communities are often overlooked or underestimated.

benefits of public health protection...’ (p.144-5). However, rural citizens experience significant health disparities5. Rural communities face geographical, personnel, infrastructure, and funding challenges and many have no formal public health or healthcare infrastructure. Local health departments, where they do exist, have less capacity and fewer resources. According to Hajat, Stewart, and Hayes, a greater proportion of rural local public health agencies (72%) list budget restrictions as a barrier to obtaining needed staff, and a higher percentage (29%) of rural respondents indicate difficulty in attracting candidates to their geographic, area compared with metropolitan Local Public Health Agencies (LPHAs)

and

suburban

LPHAs6.

The

challenge

of

maintaining, let alone strengthening, a public health workforce is greater in rural areas than urban centers because

The vast majority of the USA is rural. According to 2000 US Census data, 2292 counties (72.9%) out of a total of 3141 counties within the USA are designated as rural3. Eighty-three percent of the nation’s land is in a rural area; 25% of the nation’s population resides in a rural area. Rural communities confront challenges and limitations not faced by urban communities that affect the manner in which they are able to prevent, serve and respond to public health needs.

of a variety of issues including location, educational opportunities, and financial constraints that impact on recruitment and retention of personnel7,8. Further, the public health workforce in rural and urban areas is aging and retiring, but this is particularly so for public health nurses who provide the majority of care in rural areas9. This lack of formal public health infrastructure and trained public health professionals has a deleterious impact on rural populations.

A large number of these rural areas lack adequate health resources and are designated as health professional shortage areas (HPSAs) and/ or medically underserved areas (MUAs). According to the landmark Institute of Medicine report4, ‘no citizen from any community, no matter how small or remote should be without identifiable and realistic access to the

Public health systems are defined as ‘a complex network of individuals and organizations that have the potential to play critical roles in creating the conditions for health’10

(p.28)

.

Historically, rural communities have had to supplement public health services with the broader public health system, such as community health centers, rural health clinics or emergency medical service providers, where they exist,


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functioning as primary sources of care. Due to the lack of

serves as a catalyst for rural communities to work together to

formal public health infrastructure and trained professionals

initiate and make changes based on the local assets and

in rural areas, this broader system is critical. The broader

dynamics; (ii) provide a descriptive overview of this

public health system workers are found not only in local

strategy; and (iii) provide an illustrative case in which this

health agencies, but also in other public, private and non-

strategy has been used.

profit organizations and agencies concerned with the public’s health7. These agencies and organizations in rural areas encompass more diverse professions not usually

Background

considered part of the traditional public health workforce, including: Head Start personnel, school nurses, zoning and

The Texas A&M Health Science Center, School of Rural

planning

staff,

Public Health has pioneered a Rural Health Roundtable

community hospital workers, veterinarians, dentists, social

(RHR) strategy that has demonstrated effectiveness in

workers, tribal council members, long-term care workers,

engaging a target audience in a rural community or

home health personnel, Agency on Aging staff, community

communities; identifying local strengths and resources,

action group members, Cooperative Extension personnel,

existing relationships and gaps within the current system;

personnel,

community

health

center

8

and church members and employees .

distinguishing the broader, non-traditional rural public health system

Rural

communities

may

differ

significantly

and

additional

stakeholders;

identifying

and

across

educating local decision-makers; and working together to

geographic regions and even within the same region. This

address a specific rural health issue. This strategy has been

diversity of rural communities necessitates local solutions to

used successfully in a number of venues to elicit a wide

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local challenges . Increasingly, systems approaches that

variety of outcomes including improving local emergency

improve

social

preparedness, bioterrorism and pandemic influenza planning;

networks and expand connectivity are being used to increase

community

developing networks of interested health professionals

community planning efforts and strengthen public health

working in the HIV/AIDS arena; initiating local capacity

capacity, which ultimately lead to community collaboration,

building processes; facilitating dialog to identify local

planning, action and improved health status through

resources and access issues; and identifying coalition

sustainable community efforts. The 2002 edition of the

building, obesity prevention and rural disaster planning best

Institute of Medicine report calls for a renewed exploration

practices and success stories. Figure 1 provides an RHR

and strengthening of partnerships with the local medical

graphical overview, illustrating stakeholders and outcomes

community,

for rural community emergency planning.

voluntary

relationships,

services

strengthen

community,

media,

businesses and industry, and academic institutions necessary to have an active and robust public health system10.

The purpose of the RHR is to engage local stakeholders in a

Consequently, it is imperative that the broader rural public

face-to-face discussion about a particular public health issue.

health system collaborates locally toward a common goal of

This informal, facilitated discussion endeavors to create a

improving existing rural public health capacity and the

local network between the participants and is neither a needs

health of rural residents.

assessment nor a focus group. The Roundtable strategy lends itself to replication and application in rural communities for

The authors acknowledge that numerous models and

various public health issues.

approaches exist that engage and organize communities around community-identified problems and solutions. The purpose of this article is to: (i) suggest a strategy regularly used by the authors that encourages relationship building and


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Figure 1: Rural community emergency planning using the Rural Health Roundtable strategy.

The illustrative case for using this strategy will be provided

Methods

around rural community emergency planning. Given the lack of formal public health infrastructure, rural communities are dependent on non-traditional partners and volunteers in

The subsequent methodology for the RHR planning process is not chronological in nature; planning occurs concurrently.

preparedness planning and response. According to Nelson, Lurie, Wasserman, & Zakowski, ‘responsibility for the

Topic and target questions

preparedness of the nation’s communities lies not only with governmental agencies but also with active, engaged, and mobilized

community

residents,

businesses,

and

nongovernmental organizations’ or the broader public health system11 (p.S9).

A specific, relevant public health topic is identified for the roundtable

discussion.

Pre-determined,

discussion-

stimulating questions are used to guide the discussion. Although the discussion will differ according to each group, these questions are interrelated to ensure redirection of straying discussions. The discussion questions are designed to:


4

•

identify local strengths and assets (local resources)

‘Cold calls’ are made by telephone to potential participants

•

identify

to explain that the RHR is a two-hour, facilitated discussion,

existing

working

relationships

and

partnerships

typically held over lunch; to extend an invitation to

identify what is currently in place regarding the

participate in the Roundtable; to determine their interest; and

topic

to receive referrals of other local stakeholders who should be

•

identify best practices or success stories

invited to attend. Attempts are made to obtain a balance in

•

identify gaps or holes in existing system or services

the representatives present, so the Roundtable discussion is

regarding the topic

not too heavily weighted for any one discipline, community

identify training, learning and skill needs of

or organization.

•

•

stakeholders to enhance local capability and participants’ preferred methods for learning • •

•

Ensuring attendance

identify the extended public health network and who else should be at the table regarding the topic

After contacting potential participants by telephone, formal

collectively identify one focus issue (pick low

invitations are mailed to those indicating interest, with a

hanging fruit) which can be addressed and develop

request to RSVP. Including a map and directions to the RHR

a plan of action to allow multidisciplinary

site is helpful. All stakeholders who were previously mailed

collaboration

an invitation are phoned again prior to the Roundtable to

identify three activities that each participant would

confirm their attendance and to obtain a lunch order. This

like to accomplish in their community within the

call further encourages their attendance because the

next month.

participant has made a ‘commitment’ to a meal that will be ordered specifically for them.

Audience identification Rural health roundtable discussion Because the broader public health system is needed to supplement public health and healthcare services in rural

On the day of the Roundtable, stakeholders arrive at the site,

populations,

appropriate

sign-in, fill out a contact information form and pick up their

stakeholder categories. The stakeholder categories include

it

is

necessary

to

identify

lunch. Approximately 15 min are allowed for participants to

those disciplines within the broader public health network

get settled, begin eating and converse with other participants.

that are involved in providing services or are responsible for

This creates an informal, social environment and helps

the public health topic of interest. Stakeholder categories

encourage

will vary depending on the health topic. Within the

Roundtable begins. The facilitator extends a welcome,

community or communities participating in the RHR,

describes the purpose of the RHR and invites participants to

individual stakeholders are selected, by name, to take part in

make self-introductions. The dialogue begins with the

the Roundtable discussion. Various resources and local,

facilitator asking the target questions to guide the discussion.

regional and state contacts are utilized to identify individual

An individual other than the facilitator records detailed,

stakeholders. It is preferable that a central location within the

hand-written notes.

open

dialogue

and

discussion

once

the

community or among communities is selected to convene the Roundtable for convenience, as well as being a neutral site

On conclusion, participants are told the information they

that encourages participants to share openly. Before

discussed will be used for local planning and incorporated

selecting a date, it is helpful to contact key community

into materials or upcoming events hosted for them by the

stakeholders to ensure no conflicting meetings or activities

facilitating organization. To promote collaboration and

are scheduled for tentative dates.

problem solving using existing assets, the group collectively


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identifies a local issue and develops a plan of action to

•

address this issue. Following the Roundtable, all participants

Are more and different strengths and assets identified?

are instructed to complete a process evaluation to provide the

•

Are relationships stronger? Are networks denser?

facilitating organization with feedback and recommendations

•

Are communities improving, expanding, and/ or

and to learn of three activities participants would like to accomplish in their communities within the months

creating new best practices? •

following the Roundtable.

Are communities resolving the gaps or holes indicated at the initial Roundtable discussion?

•

Follow up

Are learning and skill needs being met? Have stakeholders sought out and attended educational and skill building activities?

Communication: It is imperative that the facilitating

•

Are necessary stakeholders involved who were not

organization continue communication with the RHR

previously involved? Did the larger group of

participants and nurture the relationships once the RHR has

stakeholders become part of the broader public

concluded. The facilitating organization can maintain contact by offering current information and resources, opportunities

health network? •

for collaboration, technical assistance and notification of upcoming events, such as continuing educational activities.

identified individually? •

Continuing education opportunities may include those offered by the facilitating organization or other activities

What progress has been made in the three activities What advancements have been made in the one area collectively identified by the group?

•

Has the group held additional meetings, developed

available throughout the region or state. Continuing

a coalition, hosted community activities etc to

education activities and other events can be used as tools to

address the public health issue?

connect rural stakeholders throughout the state or region who have similar interests. These activities and events

Results

provide additional opportunities for stakeholders to work together and continue to expand their existing network.

The RHR strategy can result in short-term, intermediate and long-term outcomes using various evaluation tools, such as

Evaluation: A follow-up evaluation may be conducted to identify and assess changes made in the community to ameliorate the selected public health issue. Detailed, specific notes taken at the Roundtable reflect the qualitative information conveyed by the participants. Notes are compiled and arranged by topic, extricating common themes, proposed participant solutions to address concerns or gaps, and best practices or success stories. This information

process evaluations and qualitative comparisons based on the roundtable discussions. While no formal quantitative evaluations have been conducted for this methodology to attest to its effectiveness in impacting the long-term health of participating communities, future plans exist to quantify existing qualitative data and to conduct social network analyses to graphically illustrate increases in network or partnership development.

establishes baseline data that can be compared with data collected during a follow-up evaluation or Roundtable

Short-term outcomes

discussion. One short-term outcome of the Roundtable process is an The baseline data is used to identify and assess change that occurred between the initial roundtable discussion and follow up. Evaluation measures include:

information exchange among community stakeholders. The discussion results in the sharing of current activities and efforts, resources available locally or regionally, and gaps in


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community planning and in the broader public health system.

meetings,

The

activities and involving other stakeholders to address the

Roundtable

discussion

reflects

the

services,

responsibilities and existing issues of attending organizations

developing

coalitions,

hosting

community

public health issue.

and agencies, as well as the collective assets available to promote partnerships and collaboration, and makes changes

Long term

based on the issues discussed. The Roundtable generates qualitative summaries of the discussion, with common

While smaller communities have limited resources available,

themes, proposed participant solutions, lessons learned and

rural community stakeholders consistently indicate that their

best practices or success stories. The Roundtable discloses

single greatest local resource is the people in the community.

and provides suggestions for issues in which the community

Based on the issues discussed, stakeholders begin working

or communities are contending and initiates further

together as team to initiate changes that can impact on the

discussions, activities or the development of resources to

long-term health of their community. Follow-up evaluations

accurately reflect comments.

and assessments can determine the effectiveness of the Roundtable

methodology

and

subsequent

community

Roundtables can also serve as a forum to promote

activities and efforts by identifying and measuring both

educational and training opportunities. There is a general

process and outcome changes that occur over time.

consensus that rural public health workers lack formal training in the concepts and principles of public health.

Illustrative case

According to the Center for Disease Control’s Public Health’s

Infrastructure

report,

78%

of

local

health

The Rural Ready Communities (RRC) project was created to

department personnel did not graduate with public health

help ensure that community health centers, rural health

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degrees . Reaching out to these rural stakeholders, through

clinics and emergency medical service providers in non-

the RHR, and notifying them of and encouraging

hospital Texas counties have an emergency plan that can be

participation in continuing education opportunities, results in

integrated with other local planning efforts. During the

a better educated and trained rural public health workforce

project period there were 65 counties in Texas without a

and increased knowledge, skills and abilities to manage

hospital. Figure 2 shows the counties in Texas without

public health issues. Further, the Roundtables serve as an

hospitals and the type of health system provider within those

opportunity to reach out to the expanded, non-traditional

counties. Twelve RHR were convened with broad groups of

rural public health system to increase their awareness and

local stakeholders to form networks for integrated planning,

knowledge of public health issues.

to identify and share rural emergency planning common themes and best practices, and to develop an emergency

Intermediate outcomes

planning guide, based on these discussions, for rural healthcare systems. While the focus of this article is on the

The intermediate outcomes of the Roundtable discussion

Roundtable strategy, the RRC project also included

include it serving as a catalyst to build stakeholder networks

development of the rural community emergency planning

in rural communities, facilitating a broader and more

guide, an advisory committee to provide project guidance

inclusive ongoing dialogue, and enhancing communication

and support, and a year-end statewide workshop to introduce

to evolve the local network that will continue once the

and instruct participants using the planning guide.

facilitating organization leaves. Local groups are empowered to take ownership, plan and problem solve with existing assets. Roundtable participants begin making actual changes in their community, such as seeking out information, holding


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County has Hospital County does not have hospital but has Community Health Center (CHC) Rural Health Clinic (RHC) CHC and RHC October 2003

Emergency Medical Service Provider Source: Office of the State Epidemiologist

Figure 2: Texas Counties without hospitals.

Short-term outcomes

other rescue workers and with the public; resources; training; partnerships and mutual aid agreements; community

The total attendance for the RHR in the RRC project was

education and awareness; interface between health and

215 attendees from 59 Texas counties with an average of

emergency personnel/ systems; and liability. Table 2 further

17.9 attendees per roundtable. Table 1 illustrates the variety

conveys the RHR discussions in terms of the common

of RHR stakeholder attendee categories involved in

themes, proposed participant solutions and best practices

improving

preparedness

identified, but this listing is by no means comprehensive. For

planning. The RHRs generated qualitative summaries of the

rural

community

emergency

the purposes of this article, best practices are loosely defined

discussion, with common themes, proposed participant

as participant-identified activities or methods that were

solutions, lessons learned and best practices or success

successful in their community. The information provided by

stories. These thematic categories included volunteers;

RHR participants enabled the creation of a rural emergency

funding; communications, both between first responders and

planning guidance document.


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Table 1: Disciplines represented at Rural Health Roundtables for the Rural Ready Communities Project • Local health authorities • County judges • City council members • Mayors • County commissioners • Emergency management coordinators • Public works • Utilities representatives • Local health professionals (registered nurses, dentists, physician assistants, nurse practitioners) • Pharmacists • Veterinarians • State game wardens • Sheriff, police, public safety departments and other law enforcement officials • Emergency medical services • Fire chiefs/ fire marshalls • Department of transportation • School superintendents

• School principals • School nurses • Local health departments • Public health nurses • Jail/ Prison Administrators • Funeral home directors • Clinic directors/ administrators • Home health agencies • Faith community representatives • Chamber of Commerce representatives • Local voluntary organizations • Cooperative extension agencies • Justices of the Peace • Airport representatives • Nursing home administrators • Councils of Government • Local businesses (large and small) • Representatives from high risk settings (nuclear facility) • CERT Program coordinators

Table 2: Rural Health Roundtables: common themes, proposed participant solutions and best practices Topic Volunteers

Discussion/comments Heavy reliance on volunteers to perform first responder roles.

Solutions Develop a list of potential volunteers.

Best practices Recruited retired nurses from surrounding urban communities.

Volunteers are often full-time employees.

Recruit ‘non-typical’ volunteers for non-healthrelated tasks.

Provided incentives to retired volunteers, such as CNEs.

The volunteer base is small and redundant. Volunteers need training prior to an event. Fear for foreign-born volunteers’ safety due to potential distrust and retaliation after a terrorist event.

Be flexible in assigning tasks to volunteers. Keep volunteers enthused with periodic meetings and trainings. Share job responsibilities among volunteers to prevent burnout.

Used the Retired Senior Volunteer Program (RSVP) to recruit volunteers. Geared volunteer responsibilities to interests and time constraints. Teamed 3-4 non-professional volunteers with one paid professional. Utilized the Ministerial Alliance to recruit volunteers from churches. Recruited and trained high school students.


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Table 2: cont’d Topic Funding

Discussion/comments Local governments don't have resources for unfunded mandates. Rural areas do not have the personnel available to write and submit grant applications. Rural areas may not qualify for funding because of population size, limited infrastructure or matching fund requirements. Local funding through donations may have been tapped out.

Solutions Funding process needs to be streamlined so that money does not run out before it reaches rural areas.

Best practices The Rural Volunteer Fire Department Assistance Program provided materiel to local jurisdictions through a cost-sharing program.

Money should be ‘dualpurpose’ to build rural health infrastructure.

The USDA Rural Community Development Initiative provides a collective grant resource.

Clear, written guidelines should be provided to locals on how money can be used. Develop a grants reference list to help locals identify available funding sources.

Governmental restrictions on spending may keep locals from purchasing needed but unapproved resources. State and federal entities do not know rural needs.

Communications

Rural areas have fewer resources from which to draw. Cell phones do not work in many rural areas. Purchase of satellite phones may be cost-prohibitive for many rural jurisdictions. There are no or few media channels in rural areas. Many rural residents do not have access to local media services.

Use a microphone or megaphone to direct the public.

Locals work with Regional Councils of Government on interoperability plans to improve communications and provide common channels for jurisdictions throughout the state.

Establish a First Call Interactive Network (Reverse 911).

Quarterly meetings are held to bring all the ‘players’ together for planning and to test the Reverse 911 system.

Prepare in advance clear, accurate, culturally appropriate, multilingual information.

Communications are streamlined by housing all first responder services in the same building using the same radio system.

Ring church bells to notify the public of an incident.

Keep the message consistent. Distribution of equipment throughout several locations in a community prevented a total shut-down of the infrastructure after tornado damage. Pre-identification of special populations has helped develop appropriate communication strategies during an event. A response to a false alarm provided an opportunity to test communication channels and modify protocols based upon lessons learned.

© CL Pennel, SL Carpender, BJ Quiram, 2008. A licence to publish this material has been given to ARHEN http://www.rrh.org.au 10

Table 2: cont’d Topic Resources

Discussion/comments Rural areas have limited resources. There is a concern about the response times when relying on mutual aid agreements with surrounding counties. Rural areas rely heavily upon local and regional resources. Morgue capacity in rural areas is a major concern; many communities do not have a funeral home. Disposal of large numbers of animal carcasses is a concern in rural communities.

Solutions Utilize non-traditional professionals if a mass inoculation is necessary. A number of existing groups found in rural areas can be used as sources for personnel and resources. Public schools can provide school buses for mass evacuation. Texas Forest Service and Public Works can provide heavy equipment. All emergency plans within the county should be ‘in the same language’ and consistent. Designate one central location for mass vaccination and dispensing. Involve all key stakeholders in the planning process.

Training

Training updates need to be provided to all volunteer groups.

School nurses are an important resource in rural areas. Conduct multidisciplinary tabletop exercises.

Best practices The greatest resource in a rural area is the community itself. The Texas Funeral Directors and Morticians Association provide refrigerated mobile trucks for mass casualties. The Office of Rural Community Affairs (ORCA) funded defibrillators and resuscitation equipment and training to rural areas. _________________________________ Schools have on- and off-campus emergency plans and exercise them regularly. Volunteer Weather Watchers are an important resource during some emergencies. A central location was designated in the community as a meeting place during an emergency. The high school football field has been designated a temporary morgue.

Some rural areas have effectively used the Community Emergency Response Team (CERT) Program to recruit and train volunteers. Funeral home directors have begun to meet locally for training instead of commuting to urban areas. Training opportunities were leveraged by participating in trainings conducted in urban areas. Associations such as the Texas Veterinary Medical Association provided training on agroterrorism. Crisis Management Training offered to school personnel was attended by other members of the response community.


Table 2: cont’d Topic Partnerships/ mutual aid

Discussion/comments The plans for various entities have not been integrated. There is concern about cooperation and collaboration among responding agencies from other jurisdictions. Individual responders do not always understand how mutual aid agreements function.

Solutions Networking with all key stakeholders is essential to improved collaboration. Most counties have mutual aid agreements at the county, regional and state levels. Engage state representatives about rural issues and needs. ______________________ Mandate certain agencies to partner as a requirement for funding. Get local elected officials involved in the planning process. Exercise and revise the emergency plan more than once a year.

Best practices The Disaster District Committee, a part of the State Emergency Management System, has been very effective in coordinating the activities of response agencies. Some counties have agreements with urban medical centers to use air ambulances. Meetings that include the volunteer workforce are scheduled in the evening. __________________________________ Each county resident is levied a fee to cover the cost of air evacuation for anyone in that county. Exercises that required interagency collaboration identified several communication problems. Flyers were continually disseminated to all key stakeholders to keep involvement high.

Rural areas have specific issues; rural counties should meet together periodically to leverage resources and discuss common areas of interest. Suggest creating regional or multi-county Emergency Management Coordinators who could foster collaboration and decrease duplication of resources.

Community education/ awareness

There is concern about how to convince the public to react when a rapid response is needed.

An animal evacuation plan is essential in rural areas. Schools could play a big part in the education of children and parents.

Schools have emergency plans, but are concerned about parents that panic.

It is important to use multiple methods when educating the public.

Surveys to determine the community's health and emergency training needs were distributed to citizens and businesses in a rural area. A coalition, convened because of concern about arsenic in the drinking water, spurred the State Health Department to act.


Table 2: cont’d Topic

Discussion/comments

Health/ emergency interface

There is a healthcare personnel shortage in rural areas. Although clinics are viewed as an asset, clinic personnel are not included in the planning process. Local healthcare personnel are not involved in the development or exercise of County Emergency Plans. ________________________ There is a lack of healthcare resources. Ambulance service does not exist in all counties.

Liability

Solutions

Best practices

Local clinics can be designated as a triage area during a disaster.

A Planned Parenthood group offered care/vaccinations to all citizens in a rural county.

Telemedicine is available in many clinics and prisons and might be used during an emergency event. Major hospitals could activate mobile teams to provide care in rural areas. ______________________ Urgent care and minor care emergency clinics established in rural areas would relieve urban emergency rooms and could function as a triage facility during an emergency.

Funding should be used to build infrastructure; it should not be limited to a possible emergency response. There is concern about the liability issues for healthcare personnel who respond to an emergency. Concerns about liability discourage medical personnel from volunteering.

CNEs, Continuing nursing education; USDA, United States Department of Agriculture.

Because there is a general consensus that rural public health

outcomes was created and mailed to 178 RHR participants,

workers lack formal training in the concepts and principles

7–9 months subsequent to the RHRs. Ninety-two evaluations

of public health, the Roundtables also served as a forum to

were returned, a response rate of 51.7%. The evaluation was

promote

The

conducted to learn about the perceived benefits of RHRs and

Roundtable was used as an opportunity to increase the

the types of activities in which Roundtable participants had

awareness and knowledge of public health issues within the

engaged after the Roundtables. Eighty-five percent of the

broader rural public health system, and to promote the

Roundtable participants perceived the RHR as having long-

statewide conference that would introduce and explain use of

term benefits for their community and/ or organization.

the planning guide.

Roundtable participants indicated that the following took

educational and

training opportunities.

place as a result of participating in the RHRs:

Intermediate outcomes • In an attempt to learn more about the impact of RHRs in the

65% met an individual at the Roundtable whom they had not previously known

RRC project, an evaluation tool to measure intermediate


•

30% contacted an individual after the Roundtable to

been refined and enhanced over the past 8 years to more

discuss emergency preparedness

effectively reach stakeholders, ensure attendance and

•

53% met with others in their county

participation, promote sharing and discussions, build

•

27% met with others in surrounding counties

stakeholder

•

28% held a collaborative meeting to discuss

communication and collaboration.

networks

and

encourage

continued

emergency preparedness and response 23% practiced their plan using a drill or tabletop

Rural community members are generally considered the

exercise

communities’ most valued asset. Through their close

•

49% participated in local planning activities

relationships,

•

37% raised community awareness or provided

experiences, rural residents bring a great deal of strength and

emergency preparedness public education

resiliency to their communities. Because the community as a

•

14% held education and/ or training activities

whole depends on each other for the common good,

•

37% attended other trainings, conferences or

residents hold one another accountable and are willing to

•

well-developed

networks

and

shared

emergency preparedness related events

spend their free time helping the community through

•

29% increased community involvement

volunteer activities associated with community schools,

•

54% shared information within their county

churches, and service organizations.

•

33% shared information among other counties

•

39% involved other organizations, agencies, or

Rural communities have fewer human and financial

individuals in planning

resources and residents cannot necessarily rely on, or have

39% involved clinics or emergency medical

access to, public health and medical professionals to assume

services in their county in the planning process

planning responsibilities. Using the RRC project as an

20% entered into Mutual Aid Agreements with

illustrative case, rural community members must be the

other counties, organizations, and/ or agencies

driving force in not only developing emergency response

11% formed a coalition for rural community

plans, but also in continually updating plans, tapping into

emergency planning

existing planning structures, exercising plans and sustaining

24% inventoried emergency and health provider

the interest and commitment of those involved. The

resources in their county

accountability and interdependence mentioned previously

34% inventoried emergency equipment, supplies, or

helps facilitate and advance the planning processes. Many

other items

rural residents fill multiple roles through various volunteer

19% purchased items/ equipment to assist in

and elected positions, serving on committees, and assisting

emergency planning or response

in community projects. These shared associations may help

28% sought out healthcare resources available in

facilitate better collaboration and cooperation among the

their county

segments of the community. Common membership in

•

32% increased volunteer participation

organizations such as parents teacher association/parent

•

27% addressed a specific topic(s) of concern.

teacher

• • • • • • •

organization,

faith-based

organizations

and

committees, athletic leagues, and civic organizations,

Discussion

encourages communication and the dissemination of information throughout the community. Key stakeholders, or

The RHR, using the methodology discussed above, has demonstrated its value as an effective tool in working with rural communities. Initiated in 1999, the methodology has

those known for ‘getting things done’, are easily identified in rural communities and this designation carries with it a credibility that allows the key stakeholders to lead, delegate and/or accomplish necessary tasks.


Members of rural communities are often required to be

multidisciplinary planning and response procedures and

particularly

emergency

practices; and the existence of shared strengths and resources

preparedness issues due to lack of local resources. With

creative

when

addressing

to enable the protection of life and property. Ultimately, it is

fewer resources at their disposal, rural communities have

a community effort with community-wide involvement that

learned to identify and utilize their unique strengths to

will enable rural areas to successfully face the challenges of

overcome resource deficits when responding to emergencies

planning for and responding to all public health emergencies.

and natural disasters. Rural communities have coped effectively with disasters in the past and have used the

It will be the responsibility of public health professionals to

lessons learned to prepare for the challenges of responding to

effectively shape the programs and policies needed to

new types of emergencies and public health threats.

improve population health during the coming century10, which should occur at the federal, state and local levels. The

Limitations

Roundtable brings together the broader, non-traditional rural public health system in face-to-face discussions to jointly

Several limitations exist for this strategy. There are

identify and address local public health issues and the local

geographic limitations in that this strategy has only been

dynamics that affect these issues. Rural Health Roundtables

utilized in rural communities in Texas, South Dakota and

can create linkages among rural stakeholders, as well as

Maine, USA. Efficacy depends on several other factors,

between rural community and other local, regional and state

including consistencies in methodology and staffing,

planning efforts, activities and resources. It serves as a

characteristics of participating community stakeholders,

catalyst of change for communities to improve their health,

continued communication and readiness of communities to

to prepare them for the unknown, and to strengthen or create

address specific public health issues. No formal quantitative

networking among neighboring communities. The RHR

evaluations have been conducted for this strategy to attest to

strategy has significant potential for replication and

its effectiveness in impacting the long-term health of

application to all areas of rural public health.

participating communities. Initial qualitative results indicate an expansion of local networks, improved collaborative

Acknowledgements

planning and increased community activities, efforts and information sharing. Additionally, the RRC project was funded by the Texas Department of State Health Services (DSHS) Hospital Preparedness Program. However, during this time period, Centers for Disease Control and Prevention Public Health Preparedness and Department of Homeland

Funding for the Rural Ready Communities project was provided by the Texas DSHS. Special thanks to the DSHS Hospital Preparedness Program and the Texas Health Institute (formerly the Texas Institute for Health Policy Research) for their collaboration on this project.

Security funding were also available at the state, regional and/or

local

levels.

The

resulting

activities

cannot

necessarily be attributed solely to this project and participation in the RHRs.

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Conclusion

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Through the RHRs, rural residents gained an understanding of the vital role of community members in planning and response

efforts;

the

importance

of

collaborative,


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